1. 7th Health Services and Policy Research Conference “You wouldn’t be dead for quids!” 5 December Chris Baggoley 1

2. Aged Care shortage chokes hospitals
Source: The Age, Thursdasy June 2, 2011

3. HEALTH REFORM - Overview
Better coordinated and localised delivery of health services
Changed responsibilities between Commonwealth and State Governments
More Sustainable Financing
New National Institutions
Greater Transparency and accountability
Overview
The National Health Reform Agreement, which was agreed by the Council of Australian Governments on August 2nd, is the culmination of a comprehensive process to review and reform key aspects of the Australian Health system.
The reforms take an already strong system and enhance its effectiveness and resilience to changing demands and challenges.
Under the National Health Reform Agreement, all Australian governments have agreed to work together in order to achieve a number of things.
People are to have improved access to public hospital services through measures designed to improve the performance of emergency departments and to reduce waiting times for elective surgery.
The financial sustainability of our public hospitals is to be strengthened through the Commonwealth’s commitment to fund a fixed proportion of the increased growth in the cost of delivering public hospital services.
Performance of our health system is to be improved through improved standards of clinical care, and new types of performance reporting across key elements of our health care systems.
Communities will have health services that are more locally responsive, through a more devolved system of managing public hospitals and a network of new primary health care organisations, Medicare Locals.
New transparency measures – in respect of both hospital financing and health system performance reporting – will mean that communities can have greater confidence that they know how resources are being used in their health system, and what results are being achieved.
The National Health Reform Agreement is also seeing a major shift in distribution of responsibilities between the Commonwealth and the States, with the Commonwealth taking full funding and policy responsibility for aged care services, including a transfer to the Commonwealth of current resourcing for aged care services from the Home and Community Care – or HACC – program, in all states and territories excluding Victoria and Western Australia.
So, while much of the commentary in the press on health reform has focused on the financial components, what I am here to talk to you about is the more comprehensive set of changes that are put in place by the new agreement.

4. BENEFITS OF NATIONAL HEALTH REFORM
An integrated and high performing health system
Easier for patients to move around the health system and receive the care they need, when and where they need it
A focus on prevention and primary health care will keep people well and out of hospital
Increased transparency on the performance of health services at a local level
National Health Reform is intended to create a modern, integrated and high performing health system that will ensure all Australians can access health care, when and where they need it.
National Health Reform will also drive integration and co-ordination of services across the health system – from primary care through to hospitals and aged care services.
A well integrated health system will make it easier for different parts of the health sector to interact with each other, providing services in a coordinated way.
This will make it is easier for people to move around the health system. It will ensure people are treated in the most appropriate way – avoiding expensive hospital services when good primary care or aged care services are what is needed.
A new Performance and Accountability Framework will drive increased transparency and improvements in performance across the entire health system. Through easily accessible nationally consistent reporting on performance of hospitals and primary health care services, all Australians will be better informed on the health services in their local area.
In particular, there will be increased information on health services at a local level and communities will have a greater say in their local health care delivery.

5. IMPROVED ACCESS TO HOSPITALS
National Emergency Access Target
90% of all ED patients across all triage categories will be admitted, referred or discharged from Emergency Departments within four hours
Elective Surgery Target
Patients to be treated within clinically recommended time will be raised from 95% to 100% by 2015
Implementation timeframe will be extended in smaller states by one year to 2016
Improved access to hospitals
The Commonwealth Government is investing close to $3.4 billion to address key pressure points in the public hospital system. This follows the recommendations of the Council of Australian Government’s Expert Panel review on the Elective Surgery and Emergency Access Targets, which all Australian governments have now agreed and committed to under the National Partnership Agreement on Improving Hospital Services. This agreement will deliver improved services for patients, including more beds, quicker emergency department services and better access to elective surgery and subacute care. Specifically,
The NPA establishes a 4-hour National Emergency Access Target for 90 percent of patients presenting to a public hospital emergency department being seen, treated and admitted or discharged within four hours;
It establishes a National Elective Surgery Target for 100 per cent of public elective surgery patients being seen within clinically recommended times, including reducing the number of patients overdue for surgery, especially those who have been waiting the longest
It provides an investment of $1.6 billion nationally to fully fund the capital and recurrent costs of 1,316 new subacute beds – or bed-equivalent services – nationally to improve patent health outcomes, functional capacity and quality of life.
Implementation of emergency department and elective surgery targets as recommended by the Expert Panel will commence from 2012 with annual reward payments tied to the progressive achievement of targets as specified in the agreement.
In respect of the sub-acute beds measure, states and territories have already developed plans to implement this initiative in their jurisdiction. Progress in delivering the additional 1,316 beds is to be monitored through a national consistent method for measuring the provision of these services. This method is in the process of being agreed between the Commonwealth and state and territory governments.

6. MAJOR EMPHASIS ON PERFORMANCE AND ACCOUNTABILITY
New Performance and Accountability Framework
National Health Performance Authority (NHPA)
Hospital Performance Reports and Health Communities Reports
Major Emphasis on Performance and Accountability
A major theme of this National Health Reform Agreement is its emphasis on a partnership between the Commonwealth and States and Territories in driving improved performance across the health system through higher national performance standards and unprecedented transparency. I have already spoken about the greater transparency that is a feature of the hospital financing arrangements; there is also a major emphasis on transparency in respect of the performance of public and private hospitals and the new Medicare Locals.
Since December last year, when Minister Roxon launched the My Hospitals website, Australians have had better access to information about the performance of the health system.
The My Hospitals website provides increased transparency on hospitals’ performance by making it possible to compare the performance of individual hospitals against the national average. The website currently provides performance information on emergency department waiting times, as well as other information about the services hospitals provide. This is the first time nationally consistent hospital level performance information has been published.
COAG has agreed that My Hospitals will move to the new National Health Performance Authority once it is established.
Legislation to establish this new body is currently before the Federal Parliament, where it passed the House of Representatives a couple of weeks ago.
The NHPA, as it’s known in acronym land, will develop and produce hospital performance reports on every hospital – public and private – in the country. It will also produce Health Communities Reports which will look at a range of factors in each Medicare Local area.
The NHPA’s reports will be driven by a Performance and Accountability Framework agreed by COAG on the advice of Health Ministers.
The NHPA itself is another of the new independent national bodies called up by the Agreement.
Of course, the Australian Commission on Safety and Quality in Health Care was established as a permanent body on 1 July this year. The commission will play an important role in developing, implementing and monitoring National Clinical Safety and Quality standards. Quality and safety indicators are amongst those that that NHPA will report against.
It is intended for the NHPA to be functioning before the end of this calendar year.

8. Hospital ‘overcrowded, overwhelmed’
Emergency doctor:
We can't cope !
Hospital ‘overcrowded, overwhelmed’
The Age – 6 October 2011

9. Wait at hospitals is a test of patients
Source: Herald Sun, Thursday June 2, 2011

10. Literature Review
“The priority is not simply devising yet more standards and indicators, but working on the nuts and bolts of how we turn measurement for improvement into tangible change in practice”
Source: Scott, I & Phelps G
“Measurement for Improvement:
Getting one to follow the other” IMJ 2009, 39,

11. Literature Review
“The available evidence suggests that targets face resistance at local level if they are imposed on those who must implement them. Mechanisms that foster participation and a sense of ownership are an important element of a target based strategy”
Source: Ernst, K., Wismar, M et al Chapter 4
“Improving the Effectiveness of Health Targets”
In “Health Targets in Europe: Learning from Experience”,
European Observatory on Health Systems and Policies, Observational Studies Series No 13, 2008

12. Literature Review
“A target should be sufficiently challenging to stimulate new and better ways of doing things rather than simply waiting for nature to take its course”
Source: McKee, M Chapter 3: On Target?
Monitoring and Evaluation in
“Health targets in Europe: Learning from
Experience” European Observatory on Health Systems and Policies 2008, Observations Studies Series No 13

13. Literature Review
“The most difficult phase of redesign is not identifying issues or designing new solutions; it is implementing those solutions and embedding the redesigned model into core business processes”
Source: O'Connell, T, Ben-Tovim, D., McCaughan B, and McGrath, K
“Health services under siege: the case for clinical
process redesign” MJC 2008, 188, S9-S13

14. Literature Review
86 cases of hospital process redesign that have not led to consistent improvements in either patient outcomes or system performance
Scott, I, Wills, R-A et al “Impact of hospital-wide
Process redesign on clinical outcomes: a comparative study of
internally versus externally led intervention” BMJ 2 & Q: 2011: 20:

15. Risks of performance targets
LITERATURE REVIEW
Risks of performance targets
“Hitting the target but missing the point”, ie quantity not quality
Alienation of key stakeholders where there is a lack of consultation, planning and communication
“Gaming” including cherry picking of patients and manipulating data
Source: Expert Panel Review of Elective and Emergency Access
Targets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 pp 15-16

16. Emergency Department Targets
Literature Review
Emergency Department Targets
Strong evidence linking ED overcrowding and access block to poorer patient outcomes in Australia
Similar association in Canada, USA and UK
ED overcrowding and access block contribute to
% excess mortality rate
Also contribute to prolonged inpatient length of stay
Source: Expert Panel Review of Elective and Emergency Access
Targets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 pp 17-18

17. Elective Surgery Targets
Literature Review
Elective Surgery Targets
Problems with Patient categorisation
Variation in use of urgency categories across surgical specialties and between hospitals
Variation according to socio-economic status of patient and remoteness from health services
Source: Expert Panel Review of Elective and Emergency Access
Targets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p.23

18. Access Block and the Introduction of
The Four Hour Rule Program in
4 Western Australia Hospitals

19. Monthly performance against the Four Hour Rule Program in Western Australia **July 2008 – April 2011

20. Elective Surgery Urgency Categories
Cat 1 Admission within 30 days desirable for a condition that has the potential to deteriorate quickly, to the point that it may become an emergency
Cat 2 Admission within 90 days desirable for a condition causing some pain, dysfunction or disability, but which is not likely to deteriorate quickly or become an emergency
Cat 3 Admission within 365 days for a condition causing minimal or no pain, dysfunction or disability, which is unlikely to deteriorate quickly and which does not have the potential to become an emergency
Source: Expert Panel Review of Elective and Emergency Access
Targets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p. 56

21. Clinical Priority Category: NSW
Cat 1 Admission within 30 days desirable for a condition that has the
potential to deteriorate quickly to the point that it may become
an emergency
Cat 2 Admission within 90 days desirable for a condition which is not
likely to deteriorate quickly or become an emergency
Cat 3 Admission within 365 days acceptable for a condition which is
unlikely to deteriorate quickly and which has little potential
to become an emergency
Cat 4 Patients who are either clinically not ready for admission (staged) and those who have deferred admission for personal reasons (deferred) (Not Ready for Care)
Source: Expert Panel Review of Elective and Emergency Access
Targets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p. 57

22. Percentage of patients by Urgency category (2009-10)
Source: Expert Panel Review of Elective and Emergency Access
Targets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p. 56

23. Guiding Principles
Targets and the changes required to meet them will require commitment right across the health and hospital system
Hospital executives will need to work in partnership with clinicians to achieve sustainable change
Clinical engagement and clinical leadership will be essential if the targets are to be met
Targets must drive clinical redesign with a whole-of-hospital approach
Clinical redesign must ensure patient safety and enhance quality of care
Source: Expert Panel Review of Elective and Emergency Access
Targets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p.13

24. Guiding Principles
Definitions to be clear and consistent across all jurisdictions
The performance of jurisdictions is not comparable
Progress towards the targets needs to be linked with continual monitoring of safety and quality performance indicators and audit
The impact of targets on demand needs to be monitored and early strategies developed to ensure achievements are sustainable
Quality of training is maintained
Source: Expert Panel Review of Elective and Emergency Access
Targets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 pp 14-15

25. A Consumer View of Health Care
“I have a right to safe and high quality care”
This means:
To be free of being infected by my hospital or health worker
To be given the right medications at the right time
To be assessed for the risk of VTE
To undergo the correct procedure, operation, test, x-ray
To be rescued if my condition unexpectedly deteriorates

26. Australian Safety and Quality Goals for Health Care
Potential areas for Goals
Healthcare Associated Infections
Medication Safety
Partnering with patients and consumers
Appropriateness of care - Cardiovascular Disease (Stroke care and Acute Coronary Syndrome) - Diabetes 26

27. 27

28. The NSQHS Standards Standard 2 Standard 1 Partnering with
Governance for Safety and
Quality in Health
Service Organisations
Standard 2
Partnering with
Consumers
Standard 3
Healthcare
Associated
Infections
Standard 10
Preventing Falls and
Harm from Falls
Standard 4
Medication
Safety
Standard 9
Recognising and
Responding to Clinical
Deterioration in Acute
Health Care
Standard 5
Patient Identification
and Procedure
Matching
The Standards will be different, but they will cover areas that are familiar to you, like infection prevention and control, falls, pressure injuries.
Throughout the process of development of reforms, the representatives from the private sector have consistently raised concerns about duplication of assessment processes. The Standards provide a single set of nationally agreed safety and quality health services standards. They will apply across all health services. Accreditation programs like Equip, ISO 9001 and QIC are all working with the Commission to eliminate the duplication that exists in these programs, adopting the NSQHS Standards and eliminating duplication from their program.
More broadly, the Commission is having discussions with other Standards setting bodies to encourage the use of the NSQHS Standards and the core S&Q standards.
States and territories have begun to look at these standards are part of licensing processes, and there is the opportunity to reduce overlap that occurs. Where they are incorporated into licensing requirements, health services should only need to be assessed once. That however doesn’t mean there won’t be additional requirements.
The Commission has commenced conversations with Health Insurers with the view to eventually reducing the reporting burden for the private sector.
Standard 8
Preventing and
Managing Pressure
Injuries
Standard 7
Blood and Blood
Products
Standard 6
Clinical
Handover 28

29. 29

30. ACSQHC: The Australian Quality Improvement Cycle

31. Antimicrobial Resistance

32. Time Line of the Rapid Rate of Resistance
There is good evidence that overall rates of antibiotic resistance correlate with the total quantity of antibiotics used, as determined by the number of individuals treated, prior exposure and the average duration of each treatment course1, 2 Patients with infections due to resistant bacteria are known to experience delayed recovery, treatment failure or even death 3.

33. You do not score points if you are silent
There are many motivated groups out there
Government is slow to react and engagement not always there , but they are listening if there is clamour
Media important, though they they like graphics
Engagement with other groups like vets can be surprisingly good (but egos can derail united front)
Careful to be seen as representative, multidisciplinary
Engagement with other medical groups, specialities disappointing
Source: Gottlieb T. Nimmo G. Med J Austr :281-3

34. Development of a National AMS Program
Activities will include:
Undertaking a formal gap analysis to identify deficits or areas to be prioritised in the national program.
Consultation with jurisdictions, clinicians, private sector, and primary care providers to develop a national plan with key stakeholders including:
Evaluation of existing resources available.
Monitoring national and international evidence regarding AMS
Developing mechanisms for implementation of AMS nationally that allows for harmonisation of the key factors and local implementation such as on-line workshops based on the formal gap analysis

36. Australian AMR Plan Steering Committee Chair – Chief Medical Officer
Animal
Agriculture
Steering Committee
Chair – Chief Medical Officer
Members – Chief Execs
Food authority
Professional organisations
NHMRC
Infection control guidelines
AMR Advisory Committee
- Community acquired
MRSA
Beta lactamases
E coli
- Research priorities
ACSQHC
Prevention Programs
Hand Hygiene
Hospital AMS
Infection control guidelines
Clinical capacity
National Surveillance
PBAC/TGA
Pharmaceutical Benefits Advisory Committee
Regulation
NPS
Campaigns
Community prescribers
Mass audience
The role of this plan would include:
implementing a comprehensive national resistance monitoring and audit system
coordinating education and stewardship programs
implementing infection prevention and control guidelines
expanding funding to support research into all aspects of antibiotic resistance
reviewing and upgrading the current regulatory system applying to antibiotics
undertaking community and consumer campaigns

37. Antimicrobial Resistance Quality Improvement cycle
Choice of antibiotic
NPS AMS
TGA
PBAC
TGx
ACSQHC
TGx Uni, Colleges NHMRC ACSQHC NPS
Research
Translation
Infection control
Programs
AICA
NHMRC
Surveillance
AGAR DUSC NAUSP PHLN BEACH NPS
Accreditation
DoHA S & T NHPA NAUSP
Data
ACSQHC
Agencies
Accreditation